Augmented reality assisted physiotherapy rehabilitation in early phase of guillain barre syndrome (AIDP)—a case report

Abstract

Background

Guillian barre syndrome is an autoimmune disease that affects the peripheral nervous system. It is acute disorder, characterized by rapidly progressing muscle weakness and ascending paralysis, and preceding infection is often one of its causes.

Case presentation

A 50-year-old male reported with muscle soreness, sensation of tingling and weakness in both upper and lower limbs. Investigations were done after admission and found that nerve conduction study indicated of acute sensory motor demyelination polyneuropathy. He struggled with his fine motor abilities and walking, making it difficult for him to complete his activities of daily living.

Intervention

A complete interdisciplinary rehabilitation program was started to reduce the patient's symptoms and enhance functional outcomes. The rehabilitation approach consisted of progressive resistance exercises (PRE) targeting the upper and lower extremities, aimed at improving muscle strength and function. Proprioceptive neuromuscular facilitation (PNF) technique was used to improve motor function and coordination, Transcutaneous Electrical Nerve Stimulation (TENS) was utilized to help the patient control his pain and discomfort, stretching exercises were also added to improve flexibility. Fine motor activities, augmented reality-based rehabilitation for hand were also included in order to increase ability and control of smaller muscle groups, which are necessary for day-to-day tasks such as dressing and eating.

Outcome assessed were Numerical pain rating scale (NPRS), Functional independence measure (FIM), Upper extremity functional scale, and modified Erasmus GBS outcome scale (MEGOS), Hughes functional grading scale (HFGS), Borg rating of perceived exertion (RPE).

Conclusion

Early incorporation of physiotherapy in patients with Guillain barre syndrome can speed up recovery, reduce number of hospitalization days and improves overall quality of life.

Introduction

Guillain-Barré Syndrome (GBS) is defined by an acute autoimmune inflammatory response, generally started by a prior infection, resulting in demyelination of peripheral and autonomic neurons and leading to fast development of sensory and motor impairment [30]. A worldwide epidemiological study done in 2009, primarily based on data from North American and European studies, discovered that the yearly prevalence of GBS is around 1.1–1.8 per hundred thousand adults and 0.6 per 100,000 children under the age of 16 [2]. It is distinguished by a rising pattern of paralysis, which typically begins with leg weakness and numbness and gradually progresses to all four limbs (tetra paresis), typically followed by participation of the cranial nerve and, in severe cases, respiratory failure [3]. GBS has several clinical variants, the most usual is Acute Inflammatory Demyelinating Polyneuropathy (AIDP), seen mainly in Western countries, causing symmetrical weakness due to nerve demyelination [4]. Acute Motor Axonal Neuropathy (AMAN) and Acute Motor and Sensory Axonal Neuropathy (AMSAN), which are commonly seen in Asia and Latin America, both cause axonal damage, with AMSAN affecting both motor and sensory nerves [5, 12]. While the most common form of GBS involves demyelination (AIDP), axonal variants- such as Acute Motor Neuropathy (AMAN) and Acute Motor-Sensory Axonal Neuropathy (AMSAN) also occur, in the immune system directly damages the nerve axons rather than myelin sheath [31, 32]. Miller Fisher Syndrome (MFS) is characterized by ophthalmoplegia, ataxia, and areflexia that are attributed to anti-GQ1b antibodies [6]. The Pharyngeal-Cervical-Brachial variation causes paralysis in the face, neck, and upper arms [4]. While GBS is frequently discussed, the demyelinating subtype, acute inflammatory demyelinating polyradiculopathy (AIDP), is its most common form in north America and Europe, accounting for approximately 97% of cases in those regions [33]. In AIDP, immune- mediated demyelination of peripheral nerves result in the typical ascending weakness, areflexia, and often sensory symptoms, with distinct pathophysiologic and electrophysiological features compared to axonal variants [34, 35]. Uncommon variants are acute panautonomic neuropathy and pure sensory GBS, which primarily affects the autonomic and sensory nerves [7]. GBS is divided into three phases for its management. The initial Acute/Ascending Phase, lasting around two to three weeks, prioritizes pain management, respiratory function maintenance, and prevention of immobilization-related complications. The Plateau Phase focuses on progressively developing mobility through aided and vigorous workouts, optimizing pulmonary function without fatigue, and building an upright posture [8]. The main presentation and complain in the patients with GBS are muscle weakness and fatigue which highlights the need for early recognition and early multidisciplinary management between the physiotherapy, and medicine, multidisciplinary, high intensity exercise enhances recovery and reduces number of hospital stay, improves function and quality of life in patients with GBS [11, 13]. Given that the present case involves a 50-year-old patient with a documented AIDP diagnosis, the subsequent physiotherapy- rehabilitation discussion has been framed to highlight AIDP-specific rehabilitation considerations, in order to align the therapeutic course with the subtype’s characteristics. This case demonstrates the patient's rehabilitation using a holistic approach, notably focusing on muscle strength. Outcome measure used for this case are Numerical pain rating scale (NPRS)- unidimensional pain scale, functional independence measure (FIM)- tracks functional status and has motor and cognitive domains, upper extremity functional scale (UEFS)- self reported questionnaire assessing daily upper limb function, modified Erasmus GBS outcome scale (MEGOS)- prognostic model predicting likelihood of independent walking at 4 and 6 months post onset, Hughes functional grading scale (HFGS)- used to categorise functional impairment severity, from healthy to needing ventilation or death (0–6), Borg rating of perceived exertion (RPE)- gives idea about subjective exertion before and after activity. The integration of conventional physiotherapy with augmented reality (AR)-based rehabilitation tools makes this case unique. While the traditional management focuses on pain control, strength training, and mobility restoration, the addition of AR technology in this case provided an immersive, engaging, and function-oriented rehabilitation experience. This novel combination not only enhanced patient motivation and adherence but also offered improved feedback for motor learning. Such integration has rarely been reported in GBS literature, thereby making this case a valuable contribution with potential implications for broader application in neurorehabilitation.

Case presentation

A 50-year-old male presented to tertiary care hospital with the complaints of weakness in both upper and lower limbs, with more notable involvement in upper limbs. Distal segments were more involved than proximal segments. The patient also reported pain in his lower limbs, along with a tingling sensation, motor dysfunction, fatigue, and severe difficulty in walking and performing fine motor tasks. There was no associated cranial nerve involvement, autonomic dysfunction or paradoxical breathing. He mentioned a history of diarrhoea 25 days prior. The weakness had progressed gradually over this period, with increasing functional limitations leading to difficulty in ambulation and fine motor activities. Despite visiting multiple hospitals, the patient had not experienced relief. Additionally, the patient denied any significant medical history, including tuberculosis, bronchial asthma, diabetes, or hypertension. After admission to the hospital, investigations were done in the form of clinical examination and nerve conduction study (NCS), which revealed a reduction in CMAP amplitude, prolonged distal motor latency (DML), and decreased conduction velocity, indicating acute sensory-motor demyelinating polyneuropathy. Physiotherapy was started 25 days after the onset of symptoms. A repeat NCS was not done after physiotherapy rehabilitation and completion of IVIG dosage.

Timeline of events

Date of admission- 27th February 2025

Date of assessment- 28th February 2025

Date of physiotherapy rehabilitation initiation- 28th February 2025

Date of post assessment- 25th April 2025

Clinical finding

The patient was conscious, cooperative and oriented to time, place and person, with Glasgow coma scale (GCS) score of E4, V5, M6. He was afebrile and hemodynamically stable, on inspection, the patient was endomorphic. On examination, deep and superficial reflexes were diminished, as shown in (Table 1). According to tone grading scale tone of bilateral upper limb and lower limb were normal (Table 2). Manual muscle testing was done for grip strength and bilateral upper limb and lower limb muscles (Table 3). Sensations were intact, Pain assessment was done using numerical pain rating scale (NPRS); the findings were 5/10 at rest and 7/10 on the movement of lower limb.

Table 1.

Variation in reflexes grading

Types of reflexes	Pre intervention	Post intervention
Superficial reflexes	1 +	2 +
Plantar	Flexor planter reflex	Flexor planter reflex
Abdominal	1 +	2 +
Deep tendon reflexes
Biceps	1 +	2 +
Triceps	1 +	2 +
Knee jerk	1 +	2 +
Ankle jerk	1 +	2 +

0: absent, 1 + : present but depressed, 2 + : brisk response; normal, 3 + : exaggerated, 4 + : clonus always abnormal

Table 2.

Variation in muscle tone (TGS)

Muscle group	Pre and post intervention
Shoulder flexors	2 +
Shoulder extensors	2 +
Shoulder abductors	2 +
Shoulder internal rotators	2 +
Shoulder external rotators	2 +
Elbow flexors	2 +
Elbow extensors	2 +
Wrist flexors	2 +
Wrist extensors	2 +
Hip flexor	2 +
Hip extensor	2 +
Knee flexor	2 +
Knee extensor	2 +
ankle dorsiflexor	2 +
Ankle planter flexor	2 +

Tone grading system (TGS): 0: no increase in tone, 1 + : decrease tone, 2 + : normal tone, 3 + : increase tone

Table 3.

Variation in muscle strength (MMT)

	Pre intervention		Post intervention
Muscle group	Right	Left	Right	Left
Shoulder flexors	4/5	4/5	4/5	4/5
Shoulder extensors	4/5	4/5	4/5	4/5
Shoulder abductors	4/5	4/5	4/5	4/5
Shoulder internal rotators	4/5	4/5	4/5	4/5
Shoulder external rotators	4/5	4/5	4/5	4/5
Elbow flexors	3/5	3/5	4/5	4/5
Elbow extensors	3/5	3/5	4/5	4/5
Wrist flexors	3/5	3/5	4/5	4/5
Wrist extensors	3/5	3/5	4/5	4/5
Grip strength	3/5	3/5	3/5	3/5
Hip flexor	3/5	3/5	4/5	4/5
Hip extensor	3/5	3/5	4/5	4/5
Hip abductors	3/5	3/5	4/5	4/5
Hip internal rotators	3/5	3/5	4/5	4/5
Hip external rotators	3/5	3/5	4/5	4/5
Knee flexor	3/5	3/5	4/5	4/5
Knee extensor	3/5	3/5	4/5	4/5
Ankle dorsiflexor	3/5	3/5	3/5	3/5
Ankle plantar flexor	3/5	3/5	3/5	3/5

0: no contraction, 1: flickering contraction, 2: full range of motion (ROM) with gravity eliminated plane, 3: full range of motion against gravity, 4: full range of motion against gravity, moderate resistance, 5: full range of motion against gravity, maximum resistance

Diagnostic assessment

Primarily, the weakness was seen in distal muscle group, which later progressed to proximal muscles. Deep tendon reflexes were diminished in the patient, he was diagnosed as acute sensory motor demyelinating polyneuropathy (AIDP) following nerve conduction velocity findings, which demonstrated CMAP amplitude is reduced with prolonged distal motor latency (DML) and reduced conduction velocity in left median, right ulnar, peroneal and left tibial nerves. Moreover, the CMAP amplitude, distal motor latency (DML) and conduction velocity could not be elicited in right median nerve. F-min latency is prolonged in right peroneal nerve. Sensory nerve action potential amplitude conduction velocity is reduced in right median, ulnar and left sural nerves. Below are the values of nerve conduction study.

Sensory nerve conduction study

Nerve/sites	Rec. site	Onset lat ms	Amp 1–2 µV	Segments	Distance mm	Velocity m/s
Wrist	Index	3.9	3.2	Wrist-index	140	36
L Median- Dig II (Antidromic)
Wrist	Index	2.5	5.2	Wrist-index	140	56
R Ulnar- Dig V (Antidromic)
Wrist	Dig V	5.7	4.9	Wrist- Dig V	110	19
L Ulnar- Dig V (Antidromic)
Wrist	Dig V	1.1	7.9	Wrist- Dig V	110	101
L Sural- Antidromic
Lat leg	Ankle	4.2	2.6	Lat leg-Ankle	120	29
R Sural- Antidromic
Lat leg	Ankle	2.3	6.6	Lat leg-Ankle	120	52

Motor nerve conduction study

Nerve/sites	Muscles	Latency ms	Amplitude mV	Segments	Dist mm	Lat Diff. ms	Velocity m/s
Wrist	APB	NR	NR	Wrist- ABP	80
Elbow	APB	NR	NR	Elbow- wrist		NR
L Median—APB
Wrist	APB	18.29	0.2	Wrist- ABP	80
Elbow	APB	32.020	0.1	Elbow- wrist	210	13.73	15.3
R Ulnar- ADM
Wrist	ADM	4.60	0.9	Wrist- ABP	80
B. Elbow	ADM	10.88	0.8	B. Elbow- wrist	240	6.27	38.3
L Ulnar- ADM
Wrist	ADM	8.58	0.7	Wrist- ABP	80
B. Elbow	ADM	12.31	0.7	B. Elbow- wrist	240	3.73	64.4
R peroneal- EDB
Ankle	EDB	26.10	0.2	Ankle- EDB	80
B. Fib head	EDB	40.21	0.2	B. Fib head- ankle	300	14.10	21.3
L peroneal- EDB
B. Fib head	EDB	24.31	0.9	Ankle- EDB	80
	EDB	29.88	0.3	B. Fib head- ankle	300	5.56	53.9
R tibial- AH
Ankle	AH	22.50	0.3	Ankle- AH	80
Knee	AH	30.71	0.2	Knee- ankle	350	8.21	42.6
L tibial- AH
Ankle	AH	12.40	0.8	Ankle- AH	80
Knee	AH	35.04	0.6	Knee- ankle	350	22.65	15.5

Nerve	F Latency ms	M Latency ms	F-M Lat ms
R Ulnar- ADM	23.8	4.9	18.9
R peroneal- EDB	59.7	26.1	33.6
R tibial- AH	28.0	30.7	2.7
L tibial- AH	28.4	15.4	13.1
L peroneal- EDB	32.5	24.9	7.6
L Ulnar- ADM	28.6	8.5	20.1

Nerve conduction study

Therapeutic intervention

After admission to the hospital, early rehabilitation was initiated. The treatment aimed to maximize neuromuscular function and to gain back patients functional independence, thereby improving quality of life. Intravenous immunoglobulin (IVIG) was given instead of plasma exchange as the primary treatment, with dose of 0.4/kg body weight daily for five days regularly [18]. Tables 4,5 and 6 gives phase wise intervention received by the patient.

Fig. 1.

Showing: hand rehabilitation

Fig. 2.

Hand rehabilitation using augmented reality

Table 4.

Phase 1 (0–2 Weeks) intervention provided to the patient

Sr no	Goals	Intervention	Rationale	Dosage
1	To educate patient and care giver	Explain GBS, its prognosis, early mobilization importance	Active participation, and prevent complications	Each therapy interaction
2	To maintain range and the properties of muscle	Active range of motion exercises for all joints	Prevents disuse atrophy	10 eps × 2 sets
3	To alleviate pain	TENS Frequency: high frequency Intensity: Adjustable Pulse duration: 200 microseconds [19]	TENS reduces neuropathic pain [20]	30 min duration
4	To improve lung capacity	Diaphragmatic breathing exercises, incentive spirometry, assisted cough techniques	Enhances alveolar ventilation	10 eps × 3 set, 3 times/day
5	To reduce fatigue	Pacing activities and structured session with rest in between	Reduces neuromuscular overload	Throughout the day
6	To enhance joint stability	Proprioceptive exercises (e.g., rhythmic stabilization on bed)	Activation of joint receptors	10–15 min/day initially
7	To improve gross and fine motor activities	PROM for fingers and wrist; basic hand activities like squeezing a soft ball, gross grasp movements	Helps in achieving loss of dexterity movements	10 min/day, 2–3 sessions/day
8	To improve balance	Rolling, bridging, multidirectional reach outs in sitting, and sit to stand activities	Prepares for later gait retraining	10 eps × 2 sets
9	To improve muscle strength	Strengthening using 1 kg of weight cuff	Provides optimal challenge for strengthening	10 reps × 1 set
10	To improve hand function using augmented reality	Augmented pegboard tasks, virtual ball grasp-release games in Fig. 1	Enhances fine motor skills [14]	10–15 min/day, 2 sessions/day

Table 5.

Phase 2 (2–4 weeks) intervention provided to the patient

Sr no	Goals	Intervention	Rationale	Dosage
1	To improve muscle strength	Strengthening using one and half kg of weight cuff	Ideal for early GBS recovery	10 eps × 1 set
2	To alleviate pain	Frequency: high frequency TENS Intensity: Adjustable Pulse duration: 250 microseconds	TENS modulates pain signals [15, 17]	20 min × 2 times/day and AROM 10 reps × 2 sets
3	To maintain lung function	Incentive spirometry; deep-breathing exercises	Prevents atelectasis	Spirometry: 10 breaths every hour
4	To enhance motor control	PNF diagonal patterns progressing to active	Improve neuromuscular re-education	2–3 sets of each
5	To improve gait	Sit-to-stand practice, walking in parallel bars, weight shifting	Prepare for ambulation	10–15 min gait training daily
6	To improve fine motor control	squeezing therapy putty, pegboard tasks, picking small objects, clothespin exercises	Necessary for ADLs	10–15 min of fine motor tasks daily
7	To improve hand function using augmented reality	progress virtual puzzles, stacking objects, and precision grips shown in (fig. 2)	Improves coordination	15–20 min/day, 2 sessions/day

Table 6.

Phase 3 (4–8 weeks) intervention provided to the patient

Sr no	Goals	Intervention	Rationale	Dosage
1	To improve muscle strength	Strengthening using two kg of weight cuff	Promotes strengthening	10 eps × 2 sets
2	To alleviate pain	Gradual weaning off TENS	Reduces dependency	10 in x once/day
3	To increase the functional capacity of lungs	Chest PNF and inspiratory muscle training (IMT)	Improves strength of respiratory muscles	5 repetitions every 45 min
4	To enhance motor control	Advanced PNF patterns with standing, dynamic weight shifts; resistance added during PNF patterns	Improves multi joint coordination	2–3 sets of PNF tasks, once daily
5	To improve gait	Overground walking without parallel bars; stair climbing training; obstacle negotiation	Restore mobility	Walking training: 15–20 min/session
6	To improve fine motor control	Precision hand exercises	Independence in self-care activities	10–15 min, 1–2 sessions/day
7	To improve hand function using augmented reality	Complex bilateral augment-based tasks, fine motor challenges	Enhances dexterity, precision	20–30 min/day, 2 sessions/day

AROM active range of motion, TA tendo Achilles, PNF proprioceptive neuromuscular facilitation, REPS repetitions, UL upper limb, LL lower limb, sec seconds, TENS transcutaneous electrical nerve stimulation

Discussion

GBS is an acute autoimmune disorder characterized by an inflammatory response, typically following an infection. This immune response leads to demyelination of the peripheral and autonomic nerves, resulting in the rapid development of motor and sensory impairments. A key clinical feature of GBS is ascending paralysis, which usually begins in the lower limbs and progresses proximally.

This case report focuses on the comprehensive physiotherapeutic management of a 50-year-old male diagnosed with GBS. Age is considered an important risk factor in the prognosis of GBS, with studies indicating the patients above 50 years tend to have slower recovery and higher residual disability rates [27]. In this case, the patients age may have contributed to the progression and recovery profile observed. The use of augmented therapy, incorporating therapeutic exercises, transcutaneous electrical nerve stimulation (TENS), and task-specific training, provided both neuromuscular re-education and symptomatic relief. Such interventions are known to facilitate synaptic plasticity, reduce maladaptive pain signals, and promote motor learning [11]. Patient exhibited distal limb pain and weakness, along with tingling sensations, which caused significant difficulties in walking and fine motor activities such as eating, writing, and using keys. These functional limitations had a considerable impact on his ability to perform activities of daily living (ADLs) [1]. When comparing our findings with published AIDP-specific rehabilitation literature, it is notable that patients with demyelinating variant often show relatively favourable recovery compared to axonal forms. For example, in cohort of children with GBS, AIDP had higher rate of complete recovery at 3 months (56%) compared with AMAN [16, 36]. The present outcome is broadly consistent with reports of structured rehabilitation programmes in AIDP. For example, in a recent case report of AIDP, early nerve conduction studies revealed characteristic demyelinating features, and rehabilitation was tailored accordingly [34, 35].

Differences between our results and other AIDP reports may relate to patient age (50 years in our case versus 30–40 years in many series), onset timing of physiotherapy, and the use of augmented reality-assisted physiotherapy techniques. These factors may influence neuromuscular re-education, remyelination support and functional adaptation in AIDP.

Evidence from the literature supports the effectiveness of physiotherapy in GBS rehabilitation. Neha et al. demonstrated through a randomized clinical trial that supervised, individualized exercise programs yield better outcomes compared to unsupervised home-based rehabilitation for GBS patients [10]. Similarly, S wankhade et al. emphasized that targeted and goal-driven physiotherapy interventions significantly accelerate recovery [9]. The functional improvements noted in this case are consistent with the findings of Khan et al., who reported that structured physiotherapy interventions enhanced Functional Independence Measure (FIM) scores and shortened hospital stays in GBS patients [28].

In this case, early initiation of physiotherapy was essential in reaching a satisfactory functional outcome. Rehabilitation intervention led to remarkable gains in muscle strength (Table 3), reduction in pain through TENS application, and improved independence in functional activities (Table 7). Post rehabilitation assessment indicated substantial improvements in outcome measures, which contributed to faster recovery and a shorter hospital stay. The present case also emphasized fine motor rehabilitation, thereby broadening the scope of recovery. Moreover, the integration of physiotherapy with intravenous immunoglobulin (IVIG) appeared beneficial, as literature suggests that while IVIG halts immune-mediated nerve damage, physiotherapy plays a complementary role in maintaining joint mobility, preventing contractures, and restoring functional capacity [29].

Table 7.

Pre and post intervention outcome measure

Outcome measure	Pre intervention (day 1)	Post- intervention (day 56)
Upper extremity functional scale [21]	28/80	56/80
Functional independence measure [25]	Motor FIM = 30/91 Cognitive FIM = 35/35 Total = 65/126	Motor FIM = 75/91 Cognitive FIM = 35/35 Total = 110/126
Modified Erasmus GBS outcome score [26]	4/9	8/12 (taken on 7th day of admission)
Numerical pain rating scale (NPRS) [22]	7	4
Hughes functional grading scale [23]	3	2
Borg rating of perceived exertion [24]	At rest- 0 After exertion- 4	At rest- 0 After exertion- 2

Moreover, the demyelinating nature of AIDP suggests that preserving myelin integrity and promoting remyelination may be more relevant than in axonal subtype; thus, therapeutic strategies such as earlier activation, neuromuscular stimulation, pain reduction, and fatigue management may have a differential impact and warrant further investigation in AIDP- focused rehabilitation.

Overall, this case emphasizes the importance for early and planned physiotherapy in the rehabilitation process of GBS patients, stressing its significance in boosting wellness, increasing strength, and promoting functional independence.

Limitation

The case report is limited by its single subject design, which prevents generalisation of outcomes to the wider AIDP population. Outcome measures were primarily functional and did not include nerve conduction study post rehabilitation. Finally, the therapy timing, dosage and augmentation protocol used may not be replicable in all clinical settings. Future studies involving larger cohort and longer follow up periods are recommended to establish stronger clinical evidence.

Conclusion

This case report highlights the importance of physiotherapy in the multicentric treatment of GBS. Personalized strength training, fine motor skill exercises, and a structured rehabilitation program notably improved the patient's functional independence measure (FIM) score, upper extremity functional scale, numerical pain rating scale (NPRS), and modified Erasmus GBS outcome score. Early commencement of physiotherapy in GBS patients accelerates recovery and improves overall quality of life. A targeted, goal-oriented rehabilitation plan not only promotes the repair of function and functional independence, but it also helps reduces psychological suffering, including stress and anxiety. This case highlights the need of incorporating physiotherapy as a critical component in the overall recovery of people with GBS.

Abbreviations

GBS

Guillain barre syndrome

NPRS

Numerical pain rating scale

FIM

Functional independence measure

UEFS

Upper extremity functional scale

MEGOS

Modified Erasmus GBS outcome scale

HFGS

Hughes functional grading scale

RPE

Borg rating of perceived exertion

MMT

Manual muscle testing

IMT

Inspiratory muscle training

PNF

Proprioceptive neuromuscular facilitation

PRE

Progressive resistive exercises

AIDP

Acute Inflammatory Demyelinating Polyradiculoneuropathy

QoL

Quality of life

IVIg

Intravenous immunoglobulins

MMRC

Modified medical research council score

TENS

Transcutaneous electrical nerve stimulation

Authors’ contributions

RS conceptualise, gave intervention and design the case report, SS guided and helped in editing.

Funding

Open access funding provided by Datta Meghe Institute of Higher Education and Research. Not funded.

Data availability

All data generated or analysed during this case report is available in this article.

Declarations

Ethics and approval and consent to participate

No ethical approval is needed and Oral consent was taken from the subject involved into the study and written consent was taken from relatives and was informed about maintaining confidentiality. All procedures were conducted in accordance with the principles outlined in the declaration of Helsinki.

Consent for publication

Written informed consent for publication of this case report and accompanying images was obtained from the patient’s family member, as the patient was unable to provide consent. The family member was fully informed about the nature of the case report, and consent was provided voluntarily.

Competing interests

The authors declare no competing interests.